Obstructive sleep apnoea and cardiovascular disease

Robust performances of a nocturnal long-term ECG algorithm for the evaluation of sleep apnea syndrome: A pilot study

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is one of the most common sleep disorders affecting nearly one billion of the global adult population, making it a major public health issue. Even if in-lab polysomnography (PSG) remains the gold standard to diagnose OSAHS, there is a growing interest to develop new solutions with more convenient at home devices enhanced with AI-based algorithms for the detection of sleep apnea. This retrospective study aimed to assess the performances of a new method based on nocturnal long-term electrocardiogram signal to detect apneas and hypopneas, in patients who performed attended in-lab PSG. After assessing the quality of the ECG signal, the new method automatically detected apneas and hypopneas using dedicated machine learning algorithm. The agreement between the new ECG-based detection method and the standard interpretation of PSG by a sleep clinician was determined in a blind manner. Eighty-five exams were included into the study with a mean bias between the proposed method and the scorer of 3.5 apneas-hypopneas/hour (/h) (95% CI -48.1 to 55.1). At a threshold of 15/h, sensibility and specificity were 93.3% and 66.7% respectively, and positive and negative predictive values were 87.5% and 80%, respectively. The proposed method using nocturnal long-term electrocardiogram signals showed very high performances to detect apneas and hypopneas. Its implementation in a simple ECG-based device would offer a promising opportunity for preliminary evaluation of patients suspected or at-risk of OSAHS.

Causal Associations of Obstructive Sleep Apnea With Cancer Risk: A Mendelian Randomization Study

BACKGROUND

Observational studies have associated obstructive sleep apnea (OSA) with a higher risk of various cancers; however, causal relationships have not yet been definitively established.

METHODS

Our study evaluated the causal impact of OSA on the risk of developing 22 different types of cancer using univariable and multivariable Mendelian randomization (MR). OSA-associated genetic instruments were obtained from the FinnGen study, which incorporates 38,998 OSA individuals and 336,659 non-OSA individuals from European descent. Summary-level data for 22 site-specific cancers were estimated from large genetic consortia and UK Biobank. We used inverse-variance weighting (IVW) as the primary analysis, along with several sensitivity analyses.

RESULTS

Univariable MR analyses indicated a causal relationship of genetic susceptibility to OSA on an increased risk of Barrett's esophagus (BE) and esophageal cancer (odds ratio [OR] = 1.32, 95% confidence interval [CI] = 1.07-1.62, p = 0.01), endometrial cancer (OR = 1.36, 95% CI = 1.16-1.60, p = 2.26E-04), and its endometrioid subtype (OR = 1.28, 95% CI = 1.04-1.59, p = 0.02). Multivariable MR, accounting for possible confounders like drinking and smoking, confirmed the causal relationships of OSA on BE and esophageal cancer, and endometrial cancer.

CONCLUSIONS

This study provided evidence regarding causal associations of OSA with higher risk of BE and esophageal cancer, and endometrial cancer.

Effects of Continuous Positive Airway Pressure on Central and Peripheral Blood Pressure in Patients with Uncontrolled Hypertension and Obstructive Sleep Apnea: The Randomized Controlled MORPHEOS Clinical Trial

Rationale: Previous studies evaluating the effect of continuous positive airway pressure (CPAP) on blood pressure (BP) among patients with obstructive sleep apnea (OSA) showed variable results. Moreover, several studies recruited patients with normal or controlled BP, and compliance with antihypertensive drug treatment was not monitored. In addition, very few studies investigated central BP in this scenario. Objectives: To evaluate whether OSA treatment is able to reduce central and peripheral BP in patients with uncontrolled hypertension (HTN) despite well-documented use of antihypertensive treatment. Methods: MORPHEOS is a multicenter randomized controlled trial designed to evaluate the effects of CPAP or placebo (nasal dilator strips [NDSs]) for 6 months in patients with moderate to severe OSA and uncontrolled HTN on office BP, ambulatory BP monitoring (ABPM), and central BP (coprimary endpoints). Uncontrolled HTN was defined by at least one abnormal parameter on ABPM after 1 month and ⩾80% adherence to medication based on a pill count. Pill counts, adherence to CPAP or NDS, and office BP were determined once per week in the first month and monthly thereafter. Results: A total of 123 patients completed the study (NDS, n = 64; CPAP, n = 59). The two groups were similar at baseline. Adherence to NDS (⩾80%) and CPAP (⩾4 hours per night) were 98.3% and 81.7%, respectively. Compared with NDSs, office systolic BP (Δ = -10 ± 16 mm Hg; P < 0.001) and diastolic BP (Δ = -7 ± 12 mm Hg; P = 0.001) were reduced significantly in the CPAP group. Despite the BP-lowering effect of CPAP not reaching statistical significance for the ABPM parameters, the rate of 24-hour ABPM control (<130/80 mm Hg) was higher in the CPAP group than in the NDS group (40.7% vs. 20%; P = 0.024). Central diastolic BP was reduced significantly (Δ = -6 ± 9 mm Hg; adjusted P = 0.029). Conclusions: CPAP improves the rates of BP control in patients with OSA and uncontrolled HTN with regular use of medications. Clinical trial registered with www.clinicaltrials.gov (NCT02270658).

The Global Burden of Obstructive Sleep Apnea

This study reviewed the global prevalence, health and socioeconomic impact, and management approaches of obstructive sleep apnea. The narrative review examined three key dimensions: (1) worldwide OSA prevalence across different regions, accounting for variations in diagnostic standards; (2) OSA's effects on health outcomes and socioeconomic conditions across diverse populations and healthcare systems; and (3) current global approaches to OSA diagnosis, treatment, and public health management. Despite advances in diagnosis and treatment, a large proportion of OSA cases remain undiagnosed or inadequately managed. The findings show that untreated OSA significantly increases public safety risks, particularly regarding motor vehicle and occupational accidents, while also creating a substantial pool of patients at high risk for systemic complications with severe impacts on overall health. There is a critical need for increased public awareness, universal screening approaches, and integrated care strategies to address this global health challenge and reduce its considerable socioeconomic burden. Our review uniquely addresses global disparities in OSA prevalence, clarifies the health and socioeconomic impacts that remain underexplored in the current literature, and suggests concrete strategies for public health and clinical management improvement worldwide.

Unraveling the Molecular Mechanisms of OSA-Related Cardiovascular Event Recurrence: A Post Hoc Analysis From the ISAACC Study

RATIONALE

Although obstructive sleep apnea (OSA) is a prevalent condition among patients with acute coronary syndrome (ACS), the impact of OSA on cardiovascular event (CVE) recurrence is not homogeneous. We previously defined a specific phenotype of first-ACS patients without previous cardiovascular disease who are at increased risk of OSA-related CVE recurrence. However, the pathobiological mechanisms whereby OSA leads to adverse cardiovascular outcomes in this singular ACS phenotype remain to be investigated.

OBJECTIVE

To characterize the molecular pathways that relate OSA with CVE recurrence.

METHODS

This post hoc analysis of the ISAACC study (NCT01335087) included subjects without previous cardiovascular disease who were hospitalized for a first ACS and developed a recurrent CVE during the follow-up. Patients underwent respiratory polygraphy and fasting blood extraction during hospitalization. Two study groups were established on the basis of the apnea-hypopnea index (AHI): untreated severe OSA (AHI≥30events/h) and non-OSA (AHI<15events/h) groups. Proteomic profiling analysis included 276 cardiovascular and inflammatory-related plasma proteins via Olink® technology.

RESULTS

Proteomics was performed in 58 patients (77.6% male, median [p25;p75] age 58.0 [51.2;65.8] years, and median BMI 28.6 [25.8;31.2]kg/m2). Thirty patients had severe OSA, and 28 subjects were considered non-OSA controls. A total of 24 plasma proteins were differentially expressed between the groups. Among these proteins, 18 were significantly associated with OSA severity parameters derived from respiratory polygraphy. Further bioinformatic analyses of OSA-related proteins revealed their involvement in several molecular pathways, mostly related to immune function, cell signaling, and inflammatory processes.

CONCLUSION

A specific proteomic profile related to OSA presence and severity was identified in the plasma of ACS patients who developed recurrent CVEs. This analysis suggests the activation of key OSA-mediated molecular pathways with potential implications for cardiovascular prognosis.

Association between body roundness index and obstructive sleep apnea among US adults: data from the 2005-2008 and 2015-2018 National Health and Nutrition Examination Survey

OSA is defined as the repeated occurrence of apnea or hypopnea during sleep caused by upper airway collapse. Obstructive sleep apnea (OSA) is characterized by a high apnea-hypopnea index (AHI) and persistent daytime sleepiness. Body roundness index (BRI), calculated using waist circumference and height, is a measure of obesity. BRI demonstrates a stronger correlation with body fat compared to BMI. However, no studies have thus far reported on the association between BRI and OSA. The data for this study were sourced from the National Health and Nutrition Examination Survey (NHANES) database (2005-2008 and 2015-2018). BRI was computed as 364.2-365.5 * (1 - [WC(m)/2π]2/[0.5 * height(m)]2)½. Statistical methods for data analysis included multivariable logistic regression, trend tests, restricted cubic spline (RCS) plots, subgroup analysis, and interaction tests, with a significance level of p < 0.05. This cross-sectional study investigated the relationship between BRI and OSA in 8106 American adults. After adjusting for all considered covariates, BRI was found to be positively associated with the risk of OSA, with each 1-unit increase in BRI raising the risk of OSA by 167% (95% CI [2.42, 2.95], p < 0.001). The positive association between BRI and OSA was consistent across all subgroups (p < 0.001). The restricted cubic spline (RCS) plot further confirmed the positive correlation between BRI and OSA prevalence (p value < 0.0001, p nonlinear < 0.0001). The results of this study demonstrate a positive correlation between BRI and OSA, suggesting that BRI could be utilized as a predictive factor for OSA. BRI could assist clinicians in the diagnosis of OSA in patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41105-024-00566-5.

Sleep and Respiratory Infections

Sleep disorders that involve circadian rhythm disruption and sleep-disordered breathing (SDB) such as obstructive sleep apnea (OSA) are closely linked to respiratory infections. SDB leads to a proinflammatory state due to intermittent hypoxia, sleep fragmentation, increased oxidative stress, and elevation of inflammatory mediators such as tumor necrosis factor (TNF), interleukin-6 (IL-6), and C-reactive protein (CRP). Furthermore, inflammatory mediator levels correlate with SDB severity, especially in people with OSA. Nocturnal microaspiration, gastroesophageal reflux, and associated comorbidities (e.g., obesity) increase the risk of community-acquired pneumonia, viral infections such as SARS-CoV-2, respiratory complications, and death. OSA has been associated with post-COVID syndrome. It also increases the risk of postoperative complications in both adults and children. Circadian rhythm disorders such as insomnia predispose to immune disorders and increase the risk of infection. Chronic conditions such as bronchiectasis, with or without concomitant cystic fibrosis, can lead to structural sleep changes and increase the risk of OSA due to chronic cough, arousals, aspirations, hypoxia, upper airway edema, and overexpression of proinflammatory cytokines. The protective effect of treatment for sleep disorders against respiratory infection is currently unknown. However, in people presenting with respiratory infection, it is important to test for SDB to prevent complications.

Further insights into influence factors of hypertension in older patients with obstructive sleep apnea syndrome: a model based on multiple centers

OBJECTIVE

To construct a novel model or a scoring system to predict hypertension comorbidity in older patients with obstructive sleep apnea syndrome (OSAS).

METHODS

A total of 1290 older patients with OSAS from six tertiary hospitals in China were enrolled. The sample was randomly divided into a modeling set (80%) and validation set (20%) using a bootstrap method. Binary logistic regression analysis was used to identify influencing factors. According to the regression coefficients, a vivid nomogram was drawn, and an intuitive score was determined. The model and score were evaluated for discrimination and calibration. The Z-test was utilized to compare the predictive ability between the model and scoring system.

RESULTS

In the multivariate analysis, age, body mass index (BMI), apnea-hypopnea index (AHI), total bilirubin (TB), high-density lipoprotein cholesterol (HDL-C), and fasting blood glucose (FBG) were significant predictors of hypertension. The area under the receiver operating characteristic curve of the model in the modeling and validation sets was 0.714 and 0.662, respectively. The scoring system had predictive ability equivalent to that of the model. Moreover, the calibration curve showed that the risk predicted by the model and the score was in good agreement with the actual hypertension risk.

CONCLUSIONS

This accessible and practical correlation model and diagram can reliably identify older patients with OSAS at high risk of developing hypertension and facilitate solutions on modifying this risk most effectively.

Use of the biopsychosocial model of functioning in physiotherapeutic evaluation of patients with obstructive sleep apnea: a survey-based study

PURPOSE

Our study aimed to analyze the use of the biopsychosocial model of functioning in the physiotherapeutic evaluation of patients with obstructive sleep apnea in Brazil.

METHODS

Physiotherapists working with sleep-related breathing disorders were included. They completed an electronic questionnaire with items related to physiotherapeutic evaluations and sociodemographic characteristics. Data were reported in descriptive statistics, and the Wilcoxon test compared the codes of the International Classification of Functioning, Disability, and Health (ICF) included in the evaluation and therapeutic objectives.

RESULTS

The sample (n = 72) had a mean age of 41.4 ± 8.3 years, and most (n = 40) worked in the Southeast region. About 43.1% of the physiotherapists held sleep therapy certifications, 87.5% worked in clinical care, and most (62.5%) only with sleep disorders. Regarding the evaluation of sleep functions, 98.6% of the physiotherapists evaluated excessive sleepiness, and sleep quality was investigated using subjective questioning (80.3%). The components considered very relevant for evaluation were activity (73.6%), followed by body functions (72.2%), environmental factors (70.8%), body structure (65.3%), and participation (63.9%). Some components were evaluated but were not often included among the therapeutic objectives, such as recreational activity (p = 0.016) and intimate relationships (p = 0.035).

CONCLUSIONS

Physiotherapists reported collecting information on all functioning components; most were activity and body function components. However, standardized evaluation tools for investigating functioning are not often applied.

Pregnancy-onset obstructive sleep apnea and ambulatory blood pressure

STUDY OBJECTIVE

Elevated nocturnal blood pressure (BP) increases the risk for hypertensive disorders of pregnancy (HDP). Though obstructive sleep apnea (OSA) increases the risk for HDP, data on OSA, and 24-hour ambulatory blood pressure monitoring (ABPM) in pregnancy are scarce. We aim to examine the BP profile of women with pregnancy-onset OSA.

METHODS

Pregnant women with overweight/obesity and snoring were recruited at <13 weeks gestation and underwent level III home sleep apnea testing and 24-hour ABPM at enrollment and at 31-34 weeks' gestation. Women with OSA at enrollment were excluded. Mean differences in nocturnal BP and 24-hour BP measurements, between women with pregnancy-onset OSA and women without OSA, were computed by multivariable linear regression.

RESULTS

Participants (40/101) had pregnancy-onset OSA (respiratory event index (REI) ≥5 events per hour) in the third trimester. Despite no significant differences in baseline BP, nocturnal systolic and diastolic BP were significantly higher in women with pregnancy-onset OSA compared to women without OSA, after adjusting for multiple covariates (mean difference 5.49 (1.45-9.52) and 3.89 (0.19-7.60), respectively). Differences in systolic BP persisted into the daytime in the OSA group. Lack of nocturnal dipping was highly prevalent in both groups, but the difference was not significant in the adjusted model.

CONCLUSIONS

Pregnancy-onset OSA in the 3rd trimester is associated with elevated nocturnal BP and daytime systolic BP. The lack of nocturnal dipping irrespective of REI cut-off in pregnant women at risk for SDB further demonstrates the limitations of REI in defining pathology in pregnancy.

The Effect of Obstructive Sleep Apnea on Subclinical Target Organ Damage in Patients With Resistant Hypertension

INTRODUCTION

Among all patients with hypertension, those with resistant hypertension (RH) have the highest rates of subclinical organ damage (SOD). The prevalence of obstructive sleep apnea (OSA) is high in RH patients, and it could contribute to SOD. We aimed to investigate how OSA and its treatment are related to SOD in a large cohort of RH patients.

METHODS

This is an ancillary analysis to the SARAH study, a multicentre observational cohort aiming to evaluate the impact of OSA on RH. Individuals with RH who were undergoing a sleep study and have information on at least one of the SOD variables (vascular, cardiac or renal damage) were selected. Patients were followed-up for three years.

RESULTS

In total, 503 subjects were included. The participants were predominantly male, obese, and the median (IQR) apnea-hypopnea index (AHI) was 15.5 (7.90-31.5)events/h. No differences in the presence of vascular or cardiac damage were observed between OSA and non-OSA patients. A lower estimated glomerular filtration rate (eGFR) was observed in participants with OSA than in those without OSA, with an adjusted effect of -8.69mL/min/1.73m2 (-13.59, -3.79; p value<0.001). Kidney damage was also greater in subjects with OSA, with an adjusted OR (95% CI) of 1.77 (1.09, 2.87; p value=0.02). The eGFR showed a linear dose-response relationship with OSA severity. Among patients treated with CPAP, lower eGFR values were observed in noncompliant subjects.

CONCLUSIONS

OSA could contribute to worsening renal function in patients with RH. No compliance with CPAP was associated with lower values of eGFR.

Pulmonary Embolism and Obstructive Sleep Apnea

Pulmonary embolism (PE) and obstructive sleep apnea (OSA) remain a major health issue worldwide with potential overlapping pathophysiological mechanisms. PE, the most severe form of venous thromboembolism, is associated with high morbidity and mortality, presenting challenges in management and prevention, especially in high-risk populations. OSA is a prevalent condition characterized by repeated episodes of upper airway closure resulting in intermittent hypoxia and sleep fragmentation. Although the understanding of epidemiological and pathogenic relationships between OSA and PE is still limited, current data suggest that interactions between these two conditions appear to be relevant. OSA is emerging as a novel risk factor for PE, potentially affecting all components of Virchow's triad: hypercoagulability, endothelial dysfunction, and venous stasis. Epidemiological studies indicate a high prevalence of undiagnosed OSA in acute PE patients. Moderate-to-severe OSA has been linked to worse clinical presentations and outcomes. Furthermore, OSA has been associated with increased risks of PE recurrence and mortality. Future research directions should include clarifying the bidirectional relationship between these conditions and evaluating the effectiveness and safety of continuous positive airway pressure therapy in improving outcomes in patients with concurrent acute PE and OSA.

Polysomnographic findings and psychiatric symptoms in patients with comorbid insomnia and sleep apnea: a retrospective study focusing on sex differences

PURPOSE

Comorbid insomnia and obstructive sleep apnea (COMISA) present significant clinical challenges, given their overlapping symptoms and detrimental effects on health. Only a few studies have explored sex differences in patients with obstructive sleep apnea (OSA) and COMISA. This retrospective study investigated sex differences in psychiatric symptoms and polysomnographic findings between patients with COMISA and those with OSA alone.

METHODS

Patients who underwent polysomnography (PSG) and completed questionnaires at a single tertiary hospital sleep center were enrolled. Patients diagnosed with OSA using PSG (apnea-hypopnea index ≥ 5) were categorized based on the Insomnia Severity Index-Korean version (ISI) into OSA without insomnia (OSA-only group; ISI < 15) and OSA with insomnia (COMISA group; ISI ≥ 15).

RESULTS

This study included 1,096 adult patients diagnosed with OSA, of whom 426 (38.9%) were in the COMISA group. COMISA was more common in women than in men (50.7% vs. 34.5%, p < 0.001). The COMISA group reported more severe subjective psychiatric symptoms, including depression, anxiety, and daytime sleepiness in both men and women. The male COMISA group had lower sleep efficiency (p = 0.02) and longer sleep latency (p = 0.002) than those had by the OSA-only group. The male COMISA group had a higher apnea-hypopnea index (p = 0.04) and a lower mean oxygen saturation (p = 0.004) than those had by the OSA-only group.

CONCLUSION

These findings highlight the importance of considering sex-specific clinical and polysomnographic characteristics when managing patients with COMISA.

Relationship between REI and PSA in patients with obstructive sleep apnea: a prospective case-control study

BACKGROUND

Obstructive sleep apnea has been associated with various urinary system diseases, including prostatic hyperplasia and nocturia. Recently, it has been linked to prostate cancer. This study investigated the relationship between the apnea hypopnea index, prostate-specific antigen (PSA) levels, and changes in PSA.

METHODS

A total of 673 male patients who received portable sleep monitoring were assessed. All participants underwent thorough health assessments, including PSA testing. Individuals in Study 1 were divided into OSA and control groups based on an REI (Respiratory event index) ≥ 15 events/h. In Study 2, 176participants from the initial study were retested for PSA after three years.

RESULTS

In Study 1, patients with OSA had significantly higher ln-transformed PSA levels than controls (P < 0.05). Ln-transformed PSA levels showed a positive correlation with the REI (r = 0.184, p = 0.015). In Study 2, after three years, the ln-transformed PSA level increased by 0.13 ng/ml in the OSA group, while it decreased by -0.05 ng/ml in the control group. The change in ln-transformed PSA was significantly higher in patients with OSA (p = 0.014). Even after adjusting for age, body mass index (BMI), smoking, hypertension, and diabetes, REI remained a significant predictor of PSA level changes (β = 0.226, 95% CI = 0.001-0.009; p = 0.008).

CONCLUSIONS

This study highlights the close relationship between REI and PSA levels in individuals with obstructive sleep apnea, indicating that REI is an independent risk factor for PSA levels. Obstructive sleep apnea may be associated with the incidence of prostate cancer.

A flexible catheter-based sensor array for upper airway soft tissues pressure monitoring

Obstructive sleep apnea is a globally prevalent concern with significant health impacts, especially when coupled with comorbidities. Accurate detection and localization of airway obstructions are crucial for effective diagnosis and treatment, which remains a challenge for traditional sleep monitoring methods. Here, we report a catheter-based flexible pressure sensor array that continuously monitors soft tissue pressure in the upper airway and facilitates at the millimeter level. The sensor's design and versatile 3D femtosecond laser fabrication process enable adaptation to diverse materials and applications. In vitro testing demonstrates high sensitivity (38.1 Ω/mmHg) and excellent stability. The sensor array effectively monitors distributed airway pressure and accurately identifies obstructions in an obstructive sleep apnea animal model. In this work, we highlight the potential of this catheter-based sensor array for long-term, continuous upper airway pressure monitoring and its prospective applications in other medical devices for pressure measurement in human body cavities.

Respiratory Pathology and Cardiovascular Diseases: A Scoping Review

Respiratory diseases and cardiovascular diseases (CVDs) have high prevalence and share common risk factors. In some respiratory diseases such as sleep apnoea and COPD, the evidence of their negative impact on the prognosis of CVDs seems clear. However, in other diseases it is less evident whether there is any direct relationship. With this in mind, our objective was to provide information that may be helpful to better understand the relationship between respiratory pathology and CVDs. There are different reasons for this relationship, such as shared risk factors, common pathophysiological mechanisms, side effects of treatment and the direct effect in the heart and great vessels of respiratory diseases. Indeed, aging and smoking are risk factors for CVDs and also for respiratory diseases such as obstructive sleep apnea (OSA), COPD and interstitial lung diseases (ILD). Furthermore, there are common pathophysiological mechanisms that affect both respiratory diseases and CVDs, such as accelerated atherosclerosis, microvascular dysfunction, endothelial dysfunction, inflammation, hypoxemia and oxidative stress. Besides that, it is well known that lung cancer, sarcoidosis and amyloidosis may directly affect the heart and great vessels. Finally, side effects of drugs for respiratory diseases and the discontinuation of treatments that are necessary for CVDs, such as β-blockers and aspirin, may have a deleterious impact on the cardiovascular system. In conclusion, the coexistence of respiratory diseases and CVDs is very common. It makes modifying diagnostic and therapeutic management necessary and is also a relevant prognostic factor.

Sequential exploratory mixed-method research of an eHealth intervention on blood pressure, sleep quality and physical activity in obstructive sleep apnoea: rationale and methodology of the Moore4Medical trial protocol

INTRODUCTION

The management of a chronic and frequent pathology, such as obstructive sleep apnoea (OSA), requires personalised programmes that implement new technology-based tools to improve the comprehensive treatment of the patient to reduce the morbidity associated with this disease. This study will evaluate the effectiveness of an eHealth tool in managing the pathophysiological consequences of OSA and how they impact the quality of life after 3 months of intervention among adults.

METHODS AND ANALYSIS

This is a mixed-method sequential exploratory study protocol. Participants will be≥18 years with a new diagnosis of moderate OSA and diagnosed with hypertension. The qualitative phase will consist of personal semistructured interviews. The quantitative phase will be a triple-blind randomised controlled trial. The experimental group (n=135) will receive an eHealth intervention using an electronic wrist device and a mobile application that will offer specific healthcare recommendations, physical activity indications and hygienic and dietary advice. These recommendations will be based on the information obtained in the qualitative phase. Those in the control group (n=135) will receive the usual educational materials from the sleep unit. The primary outcome will be blood pressure changes at 3 months. Secondary outcomes are subjective sleep quality, sleep apnoea-related parameters, daytime sleepiness, physical activity, empowerment and motivation for change, quality of life, anthropometry, cost-benefit and adherence.

ETHICS AND DISSEMINATION

Ethical approval for the study has been obtained from the Hospital Universitari Arnau de Vilanova (CEIC-2511). Results will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT05380726.

Synergic Integration of the miRNome, Machine Learning and Bioinformatics for the Identification of Potential Disease-Modifying Agents in Obstructive Sleep Apnea

INTRODUCTION

Understanding the diverse pathogenetic pathways in obstructive sleep apnea (OSA) is crucial for improving outcomes. microRNA (miRNA) profiling is a promising strategy for elucidating these mechanisms.

OBJECTIVE

To characterize the pathogenetic pathways linked to OSA through the integration of miRNA profiles, machine learning (ML) and bioinformatics.

METHODS

This multicenter study involved 525 patients with suspected OSA who underwent polysomnography. Plasma miRNAs were quantified via RNA sequencing in the discovery phase, with validation in two subsequent phases using RT-qPCR. Supervised ML feature selection methods and comprehensive bioinformatic analyses were employed. The associations among miRNA targets, OSA and OSA treatment were further explored using publicly available external datasets.

RESULTS

Following the discovery and technical validation phases in a subset of patients with and without confirmed OSA (n=53), eleven miRNAs were identified as candidates for the subsequent feature selection process. These miRNAs were then quantified in the remaining population (n=472). Feature selection methods revealed that the miRNAs let-7d-5p, miR-15a-5p and miR-107 were the most informative of OSA. The predominant mechanisms linked to these miRNAs were closely related to cellular events such as cell death, cell differentiation, extracellular remodeling, autophagy and metabolism. One target of let-7d-5p and miR-15a-5p, the TFDP2 gene, exhibited significant differences in gene expression between subjects with and without OSA across three independent databases.

CONCLUSION

Our study identified three plasma miRNAs that, in conjunction with their target genes, provide new insights into OSA pathogenesis and reveal novel regulators and potential drug targets.

Association and interaction effect of shift work and the risk for obstructive sleep apnea on diabetes mellitus in middle-aged Korean workers

PURPOSE

To investigate the association of shift work and the risk for obstructive sleep apnea (OSA) with diabetes mellitus (DM), and the interaction effect of shift work and the risk for OSA on DM.

METHODS

Data from the Korea National Health and Nutrition Examination Survey (KNHANES) 2019-2021 were used. The participants were 3012 employees aged 40 to 59 years. Shift work was assessed using self-reporting questionnaires. The risk for OSA was assessed by STOP-BANG score. The distribution of demographic factors was calculated using the chi-square test. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated using multivariable logistic regression. An interaction effect between shift work and the risk for OSA on DM was evaluated using relative excess risk owing to interaction (RERI) and attributable proportion (AP) with 95% CIs. The synergic index (SI) was also calculated.

RESULTS

Shift work and the risk for OSA were each significantly associated with DM. There was also a significant interaction effect between shift work and the risk for OSA on DM. The RERI was 0.543 (95% CI 0.205-1.361) and the AP was 0.230 (95% CI 0.145-0.342). The SI was 1.662 (95% CI 1.481-1.843).

CONCLUSIONS

There was an association and a significant interaction effect of shift work and the risk for OSA on DM. The management of OSA in shift workers should be implemented to prevent DM.

Nocturia and obstructive sleep apnoea

Nocturia, the need to urinate at night, is a common symptom in patients with obstructive sleep apnoea (OSA). Continuous positive airway pressure treatment can reduce nocturia in some patients, but the underlying mechanisms are complex and not fully understood. OSA affects the autonomic nervous system, oxidative stress and endothelial damage. Furthermore, the commonly held theory attributing polyuria to a false signal of cardiac overload and response natriuresis has limitations. A comprehensive approach to the management of nocturia in OSA, considering factors such as comorbidities, medication use, alcohol consumption and lifestyle, is needed. Effective management of nocturia in OSA requires a multidisciplinary approach, and urologists should be aware of the potential effect of OSA on physiology and refer patients for further testing at a sleep centre. In addition to continuous positive airway pressure, other interventions such as oral appliances and surgical obstruction treatment could be beneficial for some patients. Overall, understanding the complex interplay between OSA and nocturia is crucial for optimizing patient outcomes.

Renalase rs2296545 variant improve hypertension susceptibility by modifying binding affinity to catecholamines in obstructive sleep apnea

Obstructive sleep apnea (OSA), a condition often linked with hypertension, has an undefined relationship with renalase, a protein known for regulating blood pressure. This study aimed to investigate the relationship between serum renalase levels as well as renalase functional single nucleotide polymorphism (SNP) rs2296545 variant and hypertension in a Han Chinese OSA population. 126 subjects underwent serum renalase detection, with linear regression being performed to evaluate the relationship between serum renalase levels and OSA-related traits. Additional 4275 subjects were obtained rs2296545 genotype information by SNP microarray. And binary logistic regression was used to assess the effect of rs2296545 on hypertension risk. Molecular dynamics simulation and molecular docking were utilized to access the protein structures and the interplay between protein and catecholamines of wild-type and rs2296545 mutant renalase. The results showed that serum renalase levels were significantly higher in the severe OSA group. Further analysis showed renalase levels were positively correlated with blood pressure in the non-OSA group and negatively correlated in the severe OSA group. For rs2296545 polymorphism analysis, the hypertension risk significantly increased for the recessive model CC/GG + CG (OR = 1.211, 95% CI: 1.025-1.431) and the additive model CC/CG (OR = 1.223, 95% CI: 1.025-1.458) in the severe OSA. The rs2296545 polymorphism affected protein structure, and led to increase binding free energy, weakening interactions between renalase and catecholamines. In conclusion, serum renalase levels had independent association with blood pressure. And rs2296545 polymorphism may influence on susceptibility to hypertension by altering protein ability to bind to catecholamines, which might contribute to the intervention of hypertension in the OSA population.

Effect of CPAP Treatment on Cardiovascular Outcomes

INTRODUCTION

Randomized controlled trials (RCT) have not demonstrated a role for continuous positive airway pressure (CPAP) on the secondary prevention of major cardiovascular events in obstructive sleep apnea (OSA) patients. However, participants in RCTs are substantially different from real-world patients. Therefore, we aimed to assess the effect of CPAP treatment on major cardiovascular events in real-world OSA patients.

METHODS

Population-based longitudinal observational study including all OSA patients with an active CPAP prescription at the beginning of 2011 in Catalonia, Spain, that terminated CPAP treatment during 2011 and did not have CPAP prescriptions between 2012-2015; and propensity-score-matched OSA patients that continued CPAP treatment until the end of 2015 or death. Adjusted hazard ratios were used to assess the association between CPAP treatment and overall and cardiovascular mortality, cardiovascular hospitalizations, or major adverse cardiovascular events (MACEs).

RESULTS

3638 CPAP terminators and 10,914 propensity-score-matched continuators were included (median age 67 [57-77] years, 71.4% male). During a median follow-up of 47.9 months CPAP continuators showed a lower risk of cardiovascular death than terminators (hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.50-0.75) after adjusting by age, sex and key comorbidities. Similar results were found for cardiovascular hospitalizations (HR: 0.87; 95% CI: 0.76-0.99) and MACEs (HR: 0.84; 95% CI: 0.75-0.95).

CONCLUSION

CPAP treatment continuation could be associated with a significantly lower risk of major cardiovascular events in real-world OSA patients. This result highlights the importance of including real-world patients in studies on OSA.

Treatment of OSA and its Impact on Cardiovascular Disease, Part 2: JACC State-of-the-Art Review

Many studies have shown an association of obstructive sleep apnea (OSA) with incident cardiovascular diseases, particularly when comorbid with insomnia, excessive sleepiness, obesity hypoventilation syndrome, and chronic obstructive pulmonary disease. Randomized controlled trials (RCTs) have demonstrated that treatment of OSA with positive airway pressure devices (CPAP) improves systemic hypertension, particularly in those with resistant hypertension who are adherent to CPAP. However, large RCTs have not shown long-term benefits of CPAP on hard cardiovascular outcomes, but post hoc analyses of these RCTs have demonstrated improved hard outcomes in those who use CPAP adequately. In theory, low CPAP adherence and patient selection may have contributed to neutral results in intention-to-treat analyses. Only by further research into clinical, translational, and basic underlying mechanisms is major progress likely to continue. This review highlights the various treatment approaches for sleep disorders, particularly OSA comorbid with various other disorders, the potential reasons for null results of RCTs treating OSA with CPAP, and suggested approaches for future trials.

Enhanced machine learning approaches for OSA patient screening: model development and validation study

Age, gender, body mass index (BMI), and mean heart rate during sleep were found to be risk factors for obstructive sleep apnea (OSA), and a variety of methods have been applied to predict the occurrence of OSA. This study aimed to develop and evaluate OSA prediction models using simple and accessible parameters, combined with multiple machine learning algorithms, and integrate them into a cloud-based mobile sleep medicine management platform for clinical use. The study data were obtained from the clinical records of 610 patients who underwent polysomnography (PSG) at the Sleep Medicine Center of the Second Affiliated Hospital of Fujian Medical University between January 2021 and December 2022. The participants were randomly divided into a training-test group (80%) and an independent validation group (20%). The logistic regression, artificial neural network, naïve Bayes, support vector machine, random forest, and decision tree algorithms were used with age, gender, BMI, and mean heart rate during sleep as predictors to build a risk prediction model for moderate-to-severe OSA. To evaluate the performance of the models, we calculated the area under the receiver operating curve (AUROC), accuracy, recall, specificity, precision, and F1-score for the independent validation set. In addition, the calibration curve, decision curve, and clinical impact curve were generated to determine clinical usefulness. Age, gender, BMI, and mean heart rate during sleep were significantly associated with OSA. The artificial neural network model had the best efficacy compared with the other prediction algorithms. The AUROC, accuracy, recall, specificity, precision, F1-score, and Brier score were 80.4% (95% CI 76.7-84.1%), 69.9% (95% CI 69.8-69.9%), 86.5% (95% CI 81.6-91.3%), 61.5% (95% CI 56.6-66.4%), 53.2% (95% CI 47.7-58.7%), 65.9% (95% CI 60.2-71.5%), and 0.165, respectively, for the artificial neural network model. The AUROCs for the LR, NB, SVM, RF, and DT models were 80.2%, 79.7%, 79.2%, 78.4%, and 70.4%, respectively. The six models based on four simple and easily accessible parameters effectively predicted moderate-to-severe OSA in patients with PSG screening, with the artificial neural network model having the best performance. These models can provide a reliable tool for early OSA diagnosis, and their integration into a cloud-based mobile sleep medicine management platform could improve clinical decision making.

Strengthening oropharyngeal muscles as an approach to treat post-stroke obstructive sleep apnea: A feasibility randomised controlled trial

This study aimed to determine the feasibility of a randomised controlled trial (RCT) evaluating oropharyngeal exercise (OPE) intervention as an alternative therapy for obstructive sleep apnea (OSA) in patients with stroke or transient ischaemic attack (TIA). Despite the high prevalence of OSA in this population, the standard therapy, continuous positive airway pressure (CPAP), is often poorly tolerated. Thirty stroke/TIA patients with OSA unable to tolerate CPAP were randomly assigned to an oropharyngeal exercise or sham exercise protocol. They performed exercises for 6 weeks, 5 days per week, 30 minutes twice per day. Feasibility was ascertained by the proportion of enrolled patients who completed more than 80% of the OPE regimen. Isometric tongue pressures, apnea-hypopnea index (AHI), oxygen desaturation index (ODI), daytime sleepiness, and quality of life (QOL) outcomes were collected at baseline, post-training (6-week follow-up), and retention (10-week follow-up) to document preliminary efficacy. Adherence to study exercises was excellent, with 83% of participants completing more than 80% of the exercises. The isometric tongue pressures were observed to improve in the oropharyngeal exercise group (compared with the sham group), along with a decrease in OSA severity (measured by the AHI and ODI), reduced daytime sleepiness, and enhanced quality of life outcomes following the exercise programme. Only the effects on posterior isometric tongue pressure and daytime sleepiness remained significantly different between groups at the retention session. In conclusion, an RCT evaluating the efficacy of oropharyngeal exercises on post-stroke/TIA OSA is feasible and our preliminary results suggest a clinically meaningful effect.

Long-term effect of obstructive sleep apnoea management on blood pressure in patients with resistant hypertension: the SARAH study

BACKGROUND

There is a close relationship between obstructive sleep apnoea (OSA) and resistant hypertension (RH). However, studies assessing the long-term effect of diagnosing and treating OSA on blood pressure (BP) control in these patients are lacking.

METHODS

To address this gap, we recruited 478 RH patients from hypertension units and followed them prospectively after they were screened for OSA through a sleep study. By performing 24-h ambulatory BP monitoring (ABPM) annually, the effect of OSA management was assessed.

RESULTS

The patients had a median (interquartile range (IQR)) age of 64.0 (57.2-69.0) years, 67% were males and most were nonsleepy, with a median (IQR) apnoea-hypopnoea index (AHI) of 15.8 (7.9-30.7) events·h-1. The median (IQR) follow-up time was 3.01 (2.93-3.12) years. At baseline, severe OSA was associated with uncontrolled BP, nocturnal hypertension and a nondipper circadian BP pattern. Moreover, these patients had higher BP values during follow-up than did patients in the other groups. However, among patients with moderate and severe OSA, the management of sleep disordered breathing, including the implementation of continuous positive airway pressure treatment, was associated with a reduction in 24-h ABPM parameters, especially night-time BP values, at the 1-year follow-up. These benefits were attenuated over time and only subjects with severe OSA maintained an ABPM night-time reduction at 3 years. Furthermore, clinical variables such as uncontrolled BP, sex and age showed a predictive value for the BP response at 1 year of follow-up.

CONCLUSION

A favourable long-term decrease in BP was detected by diagnosing and treating OSA in a cohort of RH patients from hypertension units, but over time this decrease was only partially maintained in severe OSA patients.

Evaluation of serum salusin-α and β levels in patients with obstructive sleep apnea

Aim: Salusin-α and salusin-β peptides are crucial in the development of cardiovascular diseases like coronary artery disease (CAD). This study compared serum levels of these peptides in patients with obstructive sleep apnea (OSA), those with both OSA and CAD.Materials & methods: Patients without OSA were included in Group 1, those with OSA alone comprised Group 2, and those with OSA and CAD were in Group 3.Results: Salusin-α level was significantly higher in controls than in Groups 2 and 3, while salusin-β levels were significantly higher in Groups 2 and 3 compared with the control group.Conclusion: Salusin-α and -β levels may be parameters that can guide the diagnosis of OSA in patients with a consistent clinical history.

Obstructive sleep apnea and cardiovascular risk

Patients with obstructive sleep apnea (OSA) experience repetitive episodes of upper airway obstruction due to recurrent collapse during sleep. This leads to intermittent hypoxia episodes, which, through complex pathophysiological mechanisms, trigger sympathetic overactivation, endothelial dysfunction, hypercoagulation, and metabolic dysregulation. Consequently, other cardiovascular risk factors such as hypertension, metabolic syndrome, and diabetes are induced. Furthermore, this enhances target organ damage, affecting the heart, arteries, and kidneys, leading to an increased risk of cardiovascular morbidity and mortality. Among the various treatments for OSA, Continuous Positive Airway Pressure (CPAP) has been extensively studied. To date, this treatment has shown mild benefits in reducing blood pressure, particularly noticeable in patients with resistant hypertension. Furthermore, CPAP treatment appears to reduce cardiovascular events, both in primary and secondary prevention, though this benefit is limited to individuals with good compliance (CPAP use ≥4h/night). Future research perspectives in OSA seem to focus on identifying patients in whom the condition significantly influences cardiovascular risk, thus determining those who would benefit the most from treatment in the reduction of cardiovascular risk.

Links Between Obstructive Sleep Apnea and Myocardial Blood Flow Changes Impacting Adverse Cardiovascular Disease-related Outcomes

PURPOSE OF REVIEW

Recent studies have demonstrated an association between obstructive sleep apnea (OSA) and abnormal myocardial blood flow (MBF), myocardial flow reserve (MFR), and coronary microvascular dysfunction (CMD). Here, we review the evidence and describe the potential underlying mechanisms linking OSA to abnormal MBF. Examining relevant studies, we assess the impact of OSA-specific therapy, such as continuous positive airway pressure (CPAP), on MBF.

RECENT FINDINGS

Recent studies suggest an association between moderate to severe OSA and abnormal MBF/MFR. OSA promotes functional and structural abnormalities of the coronary microcirculation. OSA also promotes the uncoupling of MBF to cardiac work. In a handful of studies with small sample sizes, CPAP therapy improved MBF/MFR. Moderate to severe OSA is associated with abnormal MFR, suggesting an association with CMD. Evidence suggests that CPAP therapy improves MBF. Future studies must determine the clinical impact of improved MBF with CPAP.

Sleep Bruxism and Obstructive Sleep Apnea Are Not Risk Factors for Tension-Type Headache (TTH): A Polysomnographic Study

Background: Tension-type headache (TTH) is the most common primary headache. Obstructive sleep apnea (OSA) and sleep bruxism (SB) are two of the most common sleep disorders; however, the relationship between TTH, OSA, and SB has not been conclusively proved in the literature. The objective of our study was to estimate potential associations with OSA and SB in TTH subjects. Methods: 108 adult individuals who underwent polysomnography (vPSG) were included, and the group was divided into two subgroups: TTH (n = 34) and control (n = 74). The International Classification of Headache Disorders (ICHD-3) guidelines were used to diagnose TTH. OSA and SB diagnoses were based on vPSG examination with electromyographic (EMG) recordings and the American Academy of Sleep Medicine (AASM) criteria. The results were analyzed, where p < 0.05 was considered to be statistically significant. Results: In the TTH group, the incidence of SB was more than two times lower than the control (OR = 0.41, 95% CI: 0.17-0.96, p < 0.05). However, the incidence of severe SB (BEI > 4) was similar in the TTH and control groups (OR = 0.54, 95% CI: 0.21-1.35, p > 0.05). Additionally, phasic and tonic SB episodes were less frequent in the TTH group compared to the controls (p < 0.05). The mean apnea-hypopnea index (AHI) was not significantly different between the TTH and control groups (p > 0.05). The sleep architecture and respiratory disturbances did not differ between the examined groups (p > 0.05). Conclusions: SB is not a risk factor for TTH. Moreover, severe SB is not connected with TTH. OSA is not a risk factor for TTH. Sleep quality did not differ between both groups during PSG; therefore, TTH may not change sleep structure. The mechanism of these findings is still unclear, and further studies should explain in detail the association between TTH and OSA.

Predicting Alzheimer's disease CSF core biomarkers: a multimodal Machine Learning approach

Introduction

Alzheimer's disease (AD) is a progressive neurodegenerative disorder. Current core cerebrospinal fluid (CSF) AD biomarkers, widely employed for diagnosis, require a lumbar puncture to be performed, making them impractical as screening tools. Considering the role of sleep disturbances in AD, recent research suggests quantitative sleep electroencephalography features as potential non-invasive biomarkers of AD pathology. However, quantitative analysis of comprehensive polysomnography (PSG) signals remains relatively understudied. PSG is a non-invasive test enabling qualitative and quantitative analysis of a wide range of parameters, offering additional insights alongside other biomarkers. Machine Learning (ML) gained interest for its ability to discern intricate patterns within complex datasets, offering promise in AD neuropathology detection. Therefore, this study aims to evaluate the effectiveness of a multimodal ML approach in predicting core AD CSF biomarkers.

Methods

Mild-moderate AD patients were prospectively recruited for PSG, followed by testing of CSF and blood samples for biomarkers. PSG signals underwent preprocessing to extract non-linear, time domain and frequency domain statistics quantitative features. Multiple ML algorithms were trained using four subsets of input features: clinical variables (CLINVAR), conventional PSG parameters (SLEEPVAR), quantitative PSG signal features (PSGVAR) and a combination of all subsets (ALL). Cross-validation techniques were employed to evaluate model performance and ensure generalizability. Regression models were developed to determine the most effective variable combinations for explaining variance in the biomarkers.

Results

On 49 subjects, Gradient Boosting Regressors achieved the best results in estimating biomarkers levels, using different loss functions for each biomarker: least absolute deviation (LAD) for the Aβ42, least squares (LS) for p-tau and Huber for t-tau. The ALL subset demonstrated the lowest training errors for all three biomarkers, albeit with varying test performance. Specifically, the SLEEPVAR subset yielded the best test performance in predicting Aβ42, while the ALL subset most accurately predicted p-tau and t-tau due to the lowest test errors.

Conclusions

Multimodal ML can help predict the outcome of CSF biomarkers in early AD by utilizing non-invasive and economically feasible variables. The integration of computational models into medical practice offers a promising tool for the screening of patients at risk of AD, potentially guiding clinical decisions.

A risk prediction nomogram for resistant hypertension in patients with obstructive sleep apnea

Patients with obstructive sleep apnea (OSA) are liable to have resistant hypertension (RH) associated with unfavorable cardiovascular events. It is of necessity to predict OSA patients who are susceptible to resistant hypertension. Hence, we conducted a retrospective study based on the clinical records of OSA patients admitted to Yixing Hospital Affiliated to Jiangsu University from January 2018 to December 2022. According to different time periods, patients diagnosed between January 2018 and December 2021 were included in the training set (n = 539) for modeling, and those diagnosed between January 2022 and December 2022 were enrolled into the validation set (n = 259) for further assessment. The incidence of RH in the training set and external validation set was comparable (P = 0.396). The related clinical data of patients enrolled were collected and analyzed through univariate analysis and least absolute shrinkage and selection operator (LASSO) logistic regression analysis to identify independent risk factors and construct a nomogram. Finally, five variables were confirmed as independent risk factors for OSA patients with RH, including smoking, heart disease, neck circumference, AHI and T90. The nomogram established on the basis of variables above was shown to have good discrimination and calibration in both the training set and validation set. Decision curve analysis indicated that the nomogram was useful for a majority of OSA patients. Therefore, our nomogram might be useful to identify OSA patients at high risk of developing RH and facilitate the individualized management of OSA patients in clinical practice.

Association of Sex With Cardiovascular Outcomes in Heart Failure Patients With Obstructive or Central Sleep Apnea

BACKGROUND

This study investigated the association of sex with cardiovascular outcomes in a prospective cohort of patients with heart failure (HF) with obstructive sleep apnea or central sleep apnea.

METHODS AND RESULTS

Patients were screened for sleep apnea on admission using multichannel cardiopulmonary monitoring from May 2015 to July 2018. The primary outcome was a composite of cardiovascular death or unplanned hospitalization for worsening HF. Ultimately, 453 patients with HF with obstructive sleep apnea or central sleep apnea were included; 71 (15.7%) and 382 (84.3%) were women and men, respectively. During a median follow-up of 2.33 years, 248 (54.7%) patients experienced the primary outcome. In the overall population, after adjusting for potential confounders, women had an increased risk of the primary outcome (66.2% versus 52.6%; hazard ratio [HR], 1.47 [95% CI, 1.05-2.04]; P=0.024) and HF rehospitalization (62.0% versus 46.6%; HR, 1.55 [95% CI, 1.10-2.19]; P=0.013) compared with men but a comparable risk of cardiovascular death (21.1% versus 23.3%; HR, 0.78 [95% CI, 0.44-1.37]; P=0.383). Likewise, in patients with HF with obstructive sleep apnea, women had a higher risk of the primary outcome (81.8% versus 46.3%, HR, 2.37 [95% CI, 1.28-4.38]; P=0.006) and HF rehospitalization (81.8% versus 44.7%, HR, 2.46 [95% CI, 1.32-4.56], P=0.004). However, in patients with HF with central sleep apnea, there was no statistically significant difference between women and men.

CONCLUSIONS

In hospitalized patients with HF, female sex was associated with an increased risk of the primary outcome and HF rehospitalization, especially in those with obstructive sleep apnea. Screening for sleep apnea should be emphasized to improve the prognosis.

REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02664818.

Obstructive sleep apnea treatment improves temporomandibular disorder pain

PURPOSE

The existence of a bidirectional relationship between poor sleep and pain intensity has been studied, and good sleep quality has been found to be a key factor underlying pain control. The purpose of this prospective cohort study was to observe if OSA treatment provides a reduction in temporo-mandibular disorder (TMD) pain and headache attributed to TMD in patients with obstructive sleep apnea (OSA) after 18 months of OSA treatment.

METHODS

A prospective cohort study was conducted on consecutive patients suffering from OSA. Patients underwent polysomnography and TMD examination according to the DC/TMD protocol at baseline and after 18 months. Intensity of TMD pain and headache attributed to TMD were analyzed.

RESULTS

Of 40 patients (31 men, mean age 51.3 ± 10.3 years), 33 underwent OSA treatment. At the follow-up examination after 18 months, significant improvements in the intensity of pain-related TMD and headache attributed to TMD were observed (p < 0.05). Seven patients did not start treatment for OSA or discontinued treatment. These patients did not show any significant difference in intensity of TMD-pain or headache attributed to TMD after 18 months (p > 0.05).

CONCLUSIONS

Significant reductions in intensity of pain-related TMD and headache attributed to TMD were observed in patients with OSA after 18 months of OSA treatment onset, while no difference was observed in subjects not undergoing or discontinuing OSA treatment.

TRIAL REGISTRATION

The protocol was registered on ClinicalTrials.gov database with number NCT04948541.

The effects of disease severity and comorbidity on oxidative stress biomarkers in obstructive sleep apnea

PURPOSE

Ischemia-modified albumin (IMA), total oxidant status (TOS), and total antioxidant status (TAS) are biomarkers used to evaluate oxidative stress status in various diseases including obstructive sleep apnea (OSA). In this study, we investigated the effects of disease severity and comorbidity on IMA, TOS and TAS levels in OSA.

METHODS

Patients with severe OSA (no-comorbidity, one comorbidity, and multiple comorbidities) and mild-moderate OSA (no-comorbidity, one and multiple comorbidities), and healthy controls were included in the study. Polysomnography was applied to all cases and blood samples were taken from each participant at the same time of day. ELISA was used to measure IMA levels in serum samples and colorimetric commercial kits were used to perform TOS and TAS analyses. In addition, routine biochemical analyses were performed on all serum samples.

RESULTS

A total of 74 patients and 14 healthy controls were enrolled. There was no statistically significant difference between the disease groups according to gender, smoking status, age, body mass index (BMI), HDL, T3, T4, TSH, and B12 (p > 0.05). As the severity of OSA and comorbidities increased, IMA, TOS, apnea-hypopnea index (AHI), desaturation index (T90), cholesterol, LDL, triglyceride, AST, and CRP values increased significantly (p < 0.05). On the other hand, TAS, minimum desaturation, and mean desaturation values decreased significantly (p < 0.05).

CONCLUSIONS

We concluded that IMA, TOS, and TAS levels may indicate OSA-related oxidative stress, but as the severity of OSA increases and with the presence of comorbidity, IMA and TOS levels may increase and TAS levels decrease. These findings suggest that disease severity and presence/absence of comorbidity should be considered in studies on OSA.

Approach the Patient With Obstructive Sleep Apnea and Obesity

Obstructive sleep apnea (OSA) and obesity are highly prevalent and bidirectionally associated. OSA is underrecognized, however, particularly in women. By mechanisms that overlap with those of obesity, OSA increases the risk of developing, or having poor outcomes from, comorbid chronic disorders and impairs quality of life. Using 2 illustrative cases, we discuss the relationships between OSA and obesity with type 2 diabetes, dyslipidemia, cardiovascular disease, cognitive disturbance, mood disorders, lower urinary tract symptoms, sexual function, and reproductive disorders. The differences in OSA between men and women, the phenotypic variability of OSA, and comorbid sleep disorders are highlighted. When the probability of OSA is high due to consistent symptoms, comorbidities, or both, a diagnostic sleep study is advisable. Continuous positive airway pressure or mandibular advancement splints improve symptoms. Benefits for comorbidities are variable depending on nightly duration of use. By contrast, weight loss and optimization of lifestyle behaviors are consistently beneficial.

New Approaches to the Management of Cardiovascular Risk Associated with Sleep Respiratory Disorders in Pediatric Patients

Exposure to risk factors in youth can exacerbate the development of future cardiovascular disease (CVD). Obstructive sleep apnea (OSA), characterized by repetitive episodes of airway obstructions, could trigger said CVD acting as a modifiable risk factor. Measurements from echocardiography have shown impairments in the anatomy and function of the heart related to the severity of OSA. Therefore, the aim of this review was to propose a new clinical approach to the management of cardiovascular risk (CVR) in children based on treating OSA. The review includes studies assessing echocardiographic parameters for cardiac function and structure in pediatric OSA diagnosed using the apnea-hypopnea index (AHI) ≥ 1/h using polysomnography (PSG) and conducted within a year. Based on the reviewed evidence, in addition to PSG, echocardiography should be considered in OSA children in order to indicate the need for treatment and to reduce their future CVR. A follow-up echocardiography after treatment could be performed if impairments in the anatomy and function were found. Prioritizing parameters intimately connected to comorbidity could propel more effective patient-centered care. In conclusion, a reevaluation of pediatric OSA strategies should be considered, emphasizing comorbidity-related parameters in the cardiovascular field. Further studies are needed to assess this approach, potentially leading to enhanced protocols for more effective pediatric OSA treatment and CVR prevention.

Successful Virtual CPAP Set up in Obstructive Sleep Apnoea: A positive innovation during the pandemic

BACKGROUND

Traditionally continuous positive airways pressure (CPAP) trials for obstructive sleep apnoea (OSA) are through face to face (F2F) set up. During Covid-19 pandemic CPAP was classed as aerosol-generating hence Leeds sleep service moved to a virtual service. Patients received equipment by post followed by virtual reviews (VR). We evaluated the adherence and symptomatic benefit of postal compared to F2F method.

METHODS

Observational data were collected from databases monitoring CPAP loans. F2F patients met a sleep technician for hands on setup in 2019, and in 2020 postal patients received equipment, written guides, and links to custom made YouTube videos. All (F2F and postal) patients had a telephone and VR appointment to discuss symptoms, and CPAP machine (AirSense 10, ResMed Inc., San Diego, USA) data including data on usage and treatment apnoea-hypopnoea index (AHI). Data was analysed using unpaired T-tests, Mann-Whitney U tests, and chi-square tests to examine differences in means, medians, and proportions, respectively of the F2F and postal groups.

RESULTS

Both groups (n = 1,221, 656 F2F, 53.7%) were similar in all categories except length of CPAP trial (postal 33 vs F2F 84 days,p < 0.0001), change in AHI (postal 22.4/Hr vs F2F 25.1/Hr,p = 0.04), and trial average use (postal 4.9 vs F2F 5.2 h,p = 0.04). There was no significant difference in the proportion of patients continuing with CPAP (postal 64%, F2F 66%, p = 0.71), the improvement in Epworth Sleepiness Score (ESS) (postal 6.9/24, F2F 7.1/24, p = 0.31) or the patient's subjective rating on whether they felt much better, better, the same or worse on CPAP (p = 0.27). Logistic regression showed factors which affected odds ratios of continuing CPAP were diagnostic AHI, treatment AHI, treatment ESS and how they felt on CPAP. Trial type did not affect the odds ratios of continuing CPAP.

CONCLUSIONS

Postal CPAP trial patients had similar odds of continuing CPAP therapy compared to patients with F2F trials and achieved similar levels of ESS improvement and reporting feeling better on CPAP. This provides support for postal trials as a viable option post-pandemic.

Intricate relationship between obstructive sleep apnea and dementia in older adults

Numerous evidence reports direct correlation between cognitive impairment, Alzheimer's disease and sleep disorders, in particular obstructive sleep apnea. Both obstructive sleep apnea and Alzheimer's disease are highly prevalent conditions whose incidence increases with age. Several studies demonstrate how sleep-disordered breathing may lead to poor cognition, even though the underlying mechanisms of this association remain partially unclear. According to the most recent studies, obstructive sleep apnea may be considered a modifiable risk factor for cognitive dysfunction. In the present review, the authors aim to integrate recent research examining obstructive sleep apnea and Alzheimer's disease biomarkers, also focusing on the mechanisms that support this correlation, including but not limited to the role of hypoxia and cardiovascular risk. Moreover, the potential favourable effect of obstructive sleep apnea therapy on cognitive function is discussed, to evaluate the benefits deriving from appropriate treatment of sleep-disordered breathing on cognition.

Inflammation and Fibrosis in Sleep-Disordered Breathing after Acute Myocardial Infarction

BACKGROUND

After acute myocardial infarction (AMI), inflammatory processes promote tissue remodeling at the infarct site. Procollagen III amino-terminal propeptide (PIIINP) is a circulating biomarker of type III collagen synthesis that has been shown to be associated with changes in left ventricular ejection fraction (LVEF) and predicts the occurrence of heart failure after AMI. We hypothesize that sleep-disordered breathing (SDB) promotes inflammation and myocardial fibrosis, leading to reduced myocardial salvage. Therefore, in patients with first-time AMI successfully treated with percutaneous coronary intervention (PCI), we aimed to investigate whether circulating levels of high-sensitivity C-reactive protein (hs-CRP) and PIIINP are elevated in patients with SDB compared to patients without SDB.

METHODS AND RESULTS

This cross-sectional analysis included a total of 88 eligible patients with first AMI and PCI pooled from two prospective studies and stratified according to the apnea-hypopnea index (AHI, with SDB: AHI ≥ 15 h-1). We analyzed circulating levels of hs-CRP and PIIINP 3-5 days after PCI. Patients with SDB had significantly higher levels of hs-CRP (18.3 mg/L [95% CI, 8.0-42.6] vs. 5.8 mg/L [95% CI, 4.2-19.8], p = 0.002) and PIIINP (0.49 U/mL [95% CI, 0.40-0.60] vs. 0.33 U/mL [95% CI, 0.28-0.43], p < 0.001). In a multivariable linear regression model accounting for important clinical confounders, SDB significantly predicted circulating levels of hs-CRP (p = 0.028). Similarly, only SDB was independently associated with PIIINP (p < 0.001). Only obstructive but not central AHI correlated with circulating levels of hs-CRP (p = 0.012) and PIIINP (p = 0.006) levels.

CONCLUSIONS

The presence of obstructive SDB after AMI was independently associated with increased circulating levels of hs-CRP and PIIINP. Our results emphasize the important role of SDB as a common comorbidity and indicate increased inflammation and myocardial fibrosis in these patients.

Influence of microvascular mandibular bony reconstruction on the posterior airway space: A retrospective cohort study

INTRODUCTION

The posterior airway space (PAS) is a common site of passive obstructions with high morbidity. Surgical changes to the craniomandibular system may affect the PAS. Data regarding the effects of mandibular reconstruction using vascularized bone flaps on PAS are insufficient. This retrospective cohort study aimed to investigate changes in PAS after mandibular reconstruction.

MATERIALS AND METHODS

Pre- and post-reconstructive computed tomography scans of 40 patients undergoing segmental mandibulectomy and mandibular reconstruction with deep circumflex iliac artery or fibula flaps were analyzed. Absolute differences in PAS geometry and relative trends of PAS volume changes were compared within the study population and between subgroups formed according to the extent of resection, timing and type of reconstruction, and presence of pre-reconstructive radiotherapy.

RESULTS

Irradiated patients were characterized by an increase in PAS volume after reconstruction. Absolute differences in total PAS volume after reconstruction were significantly different (p = 0.024) compared to non-irradiated patients. Reconstruction of central mandible segments resulted in decrease of the cross-sectional PAS areas. Absolute differences in middle cross-sectional PAS area after reconstruction were significantly different (p = 0.039) compared to non-central reconstructions. Patients who received radiotherapy were less likely to show a total PAS volume reduction after reconstruction (OR: 0.147; p = 0.007), with values adjusted for gender, age, body mass index, timing and type of reconstruction, and transplant length.

CONCLUSIONS

Mandibular reconstruction causes changes in PAS geometry. Specifically, reconstructions of central mandibular segments can lead to a reduction in the cross-sectional areas of PAS, and mandibular reconstructions in irradiated sites may cause an increase in PAS volume.

Metabolic dysfunction-associated steatotic liver disease and the heart

The prevalence and severity of metabolic dysfunction-associated steatotic liver disease (MASLD) are increasing. Physicians who treat patients with MASLD may acknowledge the strong coincidence with cardiometabolic disease, including atherosclerotic cardiovascular disease (asCVD). This raises questions on co-occurrence, causality, and the need for screening and multidisciplinary care for MASLD in patients with asCVD, and vice versa. Here, we review the interrelations of MASLD and heart disease and formulate answers to these matters. Epidemiological studies scoring proxies for atherosclerosis and actual cardiovascular events indicate increased atherosclerosis in patients with MASLD, yet no increased risk of asCVD mortality. MASLD and asCVD share common drivers: obesity, insulin resistance and type 2 diabetes mellitus (T2DM), smoking, hypertension, and sleep apnea syndrome. In addition, Mendelian randomization studies support that MASLD may cause atherosclerosis through mixed hyperlipidemia, while such evidence is lacking for liver-derived procoagulant factors. In the more advanced fibrotic stages, MASLD may contribute to heart failure with preserved ejection fraction by reduced filling of the right ventricle, which may induce fatigue upon exertion, often mentioned by patients with MASLD. Some evidence points to an association between MASLD and cardiac arrhythmias. Regarding treatment and given the strong co-occurrence of MASLD and asCVD, pharmacotherapy in development for advanced stages of MASLD would ideally also reduce cardiovascular events, as has been demonstrated for T2DM treatments. Given the common drivers, potential causal factors and especially given the increased rate of cardiovascular events, comprehensive cardiometabolic risk management is warranted in patients with MASLD, preferably in a multidisciplinary approach.

A mediation analysis of metabolic and inflammatory factors in the severe sleep apnea-coronary heart disease association

BACKGROUND

It is unclear whether metabolic and inflammatory factors mediate the association between severe sleep apnea and coronary heart disease (CHD) in observational studies based on the large-scale population. This study aims to assess the association between severe sleep apnea and CHD and to explore the extent to which this association is mediated by metabolic factors and C-reactive protein (CRP).

METHODS

In UK Biobank, 213 442 CHD-free (mean age: 55.00) adults were followed up for 15 years to detect incident CHD. Metabolic factors included hyperglycemia, hypertension, dyslipidemia, hypertriglyceridemia, and hyperuricemia. A higher CRP concentration level was defined as a cutoff point of >3.0 mg/l. Data were analyzed using Cox proportional hazards models and the generalized structural equation model.

RESULTS

During follow-up, 9278 participants developed incident CHD (4.3%). The multi-adjusted hazard ratio and 95% confidence interval of CHD related to severe sleep apnea were 1.76 (1.44-2.15). In the mediation analysis, the strongest indirect association was for dyslipidemia, accounting for 20.8% of the association between severe sleep apnea and CHD (β = 0.22, 95% confidence interval = 0.16-0.28), followed by hypertriglyceridemia (12.3%). The proportion of mediation increased to 29.1% when CRP was added to the metabolic mediators.

CONCLUSIONS

Severe sleep apnea was associated with an increased risk of CHD. Lipid factors might play an essential role in the severe sleep apnea-CHD relationship. CRP increased the magnitude of mediation effects of overall metabolic factors. What is already known on this topic It is unknown whether the association between severe sleep apnea and CHD among the large population-based cohort study. Evidence on the mediating effect of metabolic and inflammatory factors in the severe sleep apnea-CHD association remains unclear. What this study adds Lipid factors were the biggest mediation driver in the severe sleep apnea-CHD path. C-reactive protein increased the magnitude of mediation effects of overall metabolic factors. How this study might affect research, practice or policy Investigating mediation analyses not only enhances comprehension of the pathophysiological connection between severe sleep apnea and CHD but also offers valuable insights into preventing CHD.

Acromegalic Cardiomyopathy: An Entity on its own? The Effects of GH and IGF-I Excess and Treatment on Cardiovascular Risk Factors

Acromegaly is a chronic disease resulting from constantly elevated concentrations of growth hormone (GH) and insulin-like growth factor I (IGF-I). If not adequately treated, GH and IGF-I excess is associated with various cardiovascular risk factors. These symptoms mainly include hypertension and impaired glucose metabolism, which can be observed in approximately one-third of patients. Other comorbidities are dyslipidemia and the presence of obstructive sleep apnea syndrome. However, even in the absence of conventional cardiovascular risk factors, myocardial hypertrophy can occur, which reflects the impact of GH and IGF-I excess itself on the myocardium and is defined as acromegalic cardiomyopathy. Whereas previous echocardiography-based studies reported a high prevalence of cardiomyopathy, this prevalence is much lower in cardiac magnetic resonance imaging-based studies. Myocardial hypertrophy in acromegaly is due to a homogeneous increase in the intracellular myocardial mass and extracellular myocardial matrix and improves following successful treatment through intracellular changes. Intramyocardial water retention or ectopic lipid accumulation might not be of relevant concern. Successful treatment significantly improves myocardial morphology, as well as cardiovascular risk factors. In addition to GH/IGF-I-lowering therapy, the diagnosis and treatment of cardiovascular complications is crucial for the successful management of acromegaly.

Hypoxic burden to guide CPAP treatment allocation in patients with obstructive sleep apnoea: a post hoc study of the ISAACC trial

BACKGROUND

Hypoxic burden (HB) has emerged as a strong predictor of cardiovascular risk in obstructive sleep apnoea (OSA). We aimed to assess the potential of HB to predict the cardiovascular benefit of treating OSA with continuous positive airway pressure (CPAP).

METHODS

This was a post hoc analysis of the ISAACC trial (ClinicalTrials.gov: NCT01335087) including non-sleepy patients with acute coronary syndrome (ACS) diagnosed with OSA (apnoea-hypopnoea index ≥15 events·h-1) by respiratory polygraphy. Patients were randomised to CPAP or usual care and followed for a minimum of 1 year. HB was calculated as the total area under all automatically identified desaturations divided by total sleep time. Patients were categorised as having high or low baseline HB according to the median value (73.1%min·h-1). Multivariable Cox regression models were used to assess whether the effect of CPAP on the incidence of cardiovascular outcomes was dependent on the baseline HB level.

RESULTS

The population (362 patients assigned to CPAP and 365 patients assigned to usual care) was middle-aged (mean age 59.7 years), overweight/obese and mostly male (84.5%). A significant interaction was found between the treatment arm and the HB categories. In the high HB group, CPAP treatment was associated with a significant reduction in the incidence of cardiovascular events (HR 0.57, 95% CI 0.34-0.96). In the low HB group, CPAP-treated patients exhibited a trend toward a higher risk of cardiovascular outcomes than those receiving usual care (HR 1.33, 95% CI 0.79-2.25). The differential effect of the treatment depending on the baseline HB level followed a dose-response relationship.

CONCLUSION

In non-sleepy ACS patients with OSA, high HB levels were associated with a long-term protective effect of CPAP on cardiovascular prognosis.

Changes in sleep-disordered breathing from the acute to the stable phase of pulmonary embolism: The ESAET study

BACKGROUND

/Objective: Sleep-disordered breathing (SDB) may change from the acute to stable phase of some cardiovascular disorders, but little is known whether these dynamic changes also exist in pulmonary embolism (PE). This study aimed to analyze the changes in the apnea-hypopnea index (AHI) from the acute to stable phase of PE as well as the factors associated.

PATIENTS/METHODS

We conducted a prospective, longitudinal and multicenter study of consecutive adults requiring hospitalization for non-hypotensive acute PE, with a protocol including clinical, imaging (transthoracic echocardiography [TTE] and computed tomography), blood tests and a sleep study within 48 h of diagnosis of PE. After 3 months of follow-up, the sleep study was repeated. Right ventricular (RV) dysfunction was defined according to TTE criteria.

RESULTS

One hundred and eleven patients (mean age [SD]: 63 [15] years; body mass index: 28.4 [4.7] kg/m2) were included. The initial AHI was 24.4 (21.8) events/h (AHI≥5: 82.8 %; AHI≥30: 33.3 %). Seventy-seven patients (69.4 %) had RV dysfunction. In the overall cohort, the AHI decreased by 8.7 events/h from the acute to stable phase (24.4/h vs. 15.7/h; p=0.013). Patients with RV dysfunction showed a greater decrease in AHI (mean decrease 12.3/h vs. 0.43/h). In the multivariable analysis a drop of an AHI≥5 events/hour was independently associated with the presence of initial RV dysfunction (hazard ratio 3.9; 95%CI 1.3 to 12.1).

CONCLUSIONS

In hemodynamically stable patients with acute PE, there is a transient but clinically significant decrease in the AHI from the acute to stable phase, particularly when initially presenting with RV dysfunction.

Multi-Omics Analysis of Circulating Exosomes in Adherent Long-Term Treated OSA Patients

Obstructive sleep apnea (OSA) is a highly prevalent chronic disease affecting nearly a billion people globally and increasing the risk of multi-organ morbidity and overall mortality. However, the mechanisms underlying such adverse outcomes remain incompletely delineated. Extracellular vesicles (exosomes) are secreted by most cells, are involved in both proximal and long-distance intercellular communication, and contribute toward homeostasis under physiological conditions. A multi-omics integrative assessment of plasma-derived exosomes from adult OSA patients prior to and after 1-year adherent CPAP treatment is lacking. We conducted multi-omic integrative assessments of plasma-derived exosomes from adult OSA patients prior to and following 1-year adherent CPAP treatment to identify potential specific disease candidates. Fasting morning plasma exosomes isolated from 12 adult patients with polysomnographically-diagnosed OSA were analyzed before and after 12 months of adherent CPAP therapy (mean ≥ 6 h/night) (OSAT). Exosomes were characterized by flow cytometry, transmission electron microscopy, and nanoparticle tracking analysis. Endothelial cell barrier integrity, wound healing, and tube formation were also performed. Multi-omics analysis for exosome cargos was integrated. Exosomes derived from OSAT improved endothelial permeability and dysfunction as well as significant improvement in tube formation compared with OSA. Multi-omic approaches for OSA circulating exosomes included lipidomic, proteomic, and small RNA (miRNAs) assessments. We found 30 differentially expressed proteins (DEPs), 72 lipids (DELs), and 13 miRNAs (DEMs). We found that the cholesterol metabolism (has04979) pathway is associated with lipid classes in OSA patients. Among the 12 subjects of OSA and OSAT, seven subjects had complete comprehensive exosome cargo information including lipids, proteins, and miRNAs. Multi-omic approaches identify potential signature biomarkers in plasma exosomes that are responsive to adherent OSA treatment. These differentially expressed molecules may also play a mechanistic role in OSA-induced morbidities and their reversibility. Our data suggest that a multi-omic integrative approach might be useful in understanding how exosomes function, their origin, and their potential clinical relevance, all of which merit future exploration in the context of relevant phenotypic variance. Developing an integrated molecular classification should lead to improved diagnostic classification, risk stratification, and patient management of OSA by assigning molecular disease-specific therapies.